Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

NJ Provider Network Director

📁
Director and Equivalent
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200N0 Requisition #
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Direct resources dedicated to expanding Provider Network services across the state of New Jersey, on behalf of the Emblem enterprise. Responsible for all contracting activities and negotiations with facilities and providers across New Jersey for medical, pharmacy and behavioral health services on behalf of the Emblem enterprise. Manage the ongoing day-to-day operations of all expansion efforts, including monitoring and tracking performance outcomes, ensuring compliance with relevant regulation, and facilitating cross-functional integration. Identify gaps in the expansion process including the need for additional capital and personnel resources.


Responsibilities:

  • Identify and recruit providers as necessary to ensure the development of a provider network compliant with DOBI (NJ) and CMS network adequacy requirements.
  • Ensure provider demographic and rate related information is captured and properly loaded in all Emblem systems consistent with company policy (TruProvider, Credentialing, etc.).
  • Ensure all NJ regulatory filing requirements are met.
  • Ensure all necessary vendor relationship are maintained (e.g. Quest Analytics)
  • Recruit, manage/oversee the training of new employees, as well as developing and applying appropriate policies and procedures for NJ Network activities, including compliance.
  • Ensure the design of the New Jersey expansion to meet set goals across all lines of business.
  • Direct the ongoing operations of NJ Provider Network, including the development of reports to measure the overall functioning of the Unit, such as benchmarks to track performance, and monitor daily performance of the NJ team to ensure adherence to all performance metrics.
  • Prepare all required narrative reports, such as annual program description and program evaluation.
  • Participate in the evaluation and recruitment of vendors for specialized services.
  • Demonstrate ability to work within a matrixed organization and communicate and collaborate effectively with other departments within the company, including Medical Policy, Grievances & Appeals, IT, Credentialing, Contracting, Provider Relations, Quality Improvement, Sales and Marketing, Government Affairs, and HR.
  • Work closely with Sales Team to represent the unit to health plan clients and other customers during client management meetings.
  • Demonstrate an understanding of unique client needs and ability to proactively identify and implement programs around such needs.
  • Understand the design and functionality of clinical information systems and possess the ability to interact effectively with IT support staff.
  • Understand and analyze clinical and administrative reports and use analysis to recommend policy, procedural, and operational changes.
  • Provide administrative oversight, including direct supervision of all managers, and participate in cross-functional standing committees as requested.
  • Participate in the recruitment and selection of candidates for all positions.
  • Monitor daily performance of staff to ensure adherence to all performance metrics and promptly identify necessary corrective actions.
Qualifications:
  • Bachelor’s degree; Master’s preferred.
  • 10+ years of relevant professional work experience in an operations-focused health  plan role.
  • 5 or more years of experience at a health plan in a managerial or higher position.
  • Proven ability to effectively manage in a matrix organization.
  • Previous experience with implementation and expansion of a health plan business unit or division.
  • Understanding of and relevant experience in commercial, Medicare, and Medicaid populations and lines of business.
  • Familiarity with and understanding of the local tristate market, i.e., facilities and providers within New York, New Jersey, and/or Connecticut.
  • Proven effective communications skills (verbal, written, presentation) with all types and levels of audiences.
  • Proficiency with MS Office applications (word processing, database/spreadsheet, presentation.

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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